Young-onset stroke with clinicoradiological discordance: a report of two cases

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Young-onset acute ischemic stroke with clinicoradiological discordance (n=2). Intervention: Multimodal neuroimaging and secondary stroke prevention (acetylsalicylic acid and atorvastatin). Primary outcome: Clinical neurological status (NIHSS score and MRC muscle strength) and neuroimaging findings at discharge.

Q: What does this research mean for the field?

Young-onset ischemic stroke can present with marked clinicoradiological discordance, including persistent focal neurological deficits in the absence of MRI-detectable acute infarction. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Johanes Aprilius Falerio Kristijanto; Anang Triadi; Faishol Hamdani; Azis Abdullah; Yahya Assegaff

doi:10.37897/rjn.2026.3.16

July 28, 2026Romanian Journal of NeurologyOpen Access

Young-onset stroke with clinicoradiological discordance: a report of two cases

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Key result

Young-onset stroke cases highlight clinicoradiological discordance between neuroimaging findings and neurological deficits.

n=2

Why the study?

Young-onset stroke can present with discordance between clinical findings and imaging, requiring integration of clinical assessment, multimodal imaging, and etiological evaluation.

Key Points

To describe clinicoradiological discordance and diagnostic challenges in young adults presenting with acute focal neurological deficits.
Clinical, laboratory, and multimodal neuroimaging evaluation of two young adults presenting with acute focal neurological deficits.
Diagnostic investigations included noncontrast head CT, brain MRI with diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences, vascular imaging (CTA, MRA, MRV), and cardiac evaluations.
Case 1 (25-year-old man): Initial NIHSS score was 13 with expressive aphasia and right hemiplegia; CT showed a hyperdense left middle cerebral artery sign and MRI confirmed early subacute left frontotemporal infarction with cryptogenic etiology, with discharge NIHSS of 12 and right lower-limb strength of MRC grade 2/5 on day 7.
Case 2 (21-year-old woman): Initial NIHSS score was 3 with left hemiparesis (MRC 4/5); CT demonstrated diffuse sulcal effacement, but MRI (with DWI/ADC) and vascular imaging showed no acute infarction or occlusion, remaining clinically suspected ischemic stroke without MRI confirmation at day 4 discharge.

Study Design

Type

Case Report (n=2)

Multicenter

No

Structured PICO

P

Population

2 young adults (a 25-year-old male and a 21-year-old female) in Indonesia presenting with acute focal neurological deficits and clinicoradiological discordance, followed during hospitalization for 4 to 7 days.

E

Exposure

Case 1: acetylsalicylic acid 80 mg once daily and atorvastatin 40 mg once daily; Case 2: acetylsalicylic acid 80 mg once daily.

O

Outcome

Clinical and neurological status at hospital discharge (Case 1 at day 7; Case 2 at day 4) and clinicoradiological characterization via multimodal neuroimaging (CT, MRI, MRA, MRV) and cardiac evaluation (ECG, TTE).

These two cases of young-onset stroke highlight the diagnostic challenges of clinicoradiological discordance—specifically, MRI-confirmed infarction with an uncertain embolic mechanism versus clinically suspected stroke with negative MRI—underscoring the need to integrate clinical assessment, multimodal imaging, and systematic etiological evaluation.

Limitations

Incomplete vascular imaging (unsuccessful MRA and unavailable CTA) in Case 1 prevented definitive identification of the thromboembolic source and precluded formal ESUS classification.
Transesophageal echocardiography (TEE), carotid imaging, and advanced perfusion imaging were unavailable at the facility.
Cerebral edema on CT in Case 2 was nonspecific, and the absence of a demonstrable infarct on MRI limited etiological certainty and incomplete exclusion of stroke mimics.
Short in-hospital follow-up (4 to 7 days) and subsequent loss to follow-up of Case 2 precluded assessment of long-term neurological outcomes, functional recovery, and radiological evolution.
In Case 1, incomplete vascular imaging (unsuccessful MRA due to patient agitation and no CT angiography) prevented definitive identification of the suspected thromboembolic source and precluded formal ESUS classification.
Transesophageal echocardiography (TEE), advanced perfusion imaging, and carotid imaging were unavailable at the facility.
In Case 2, cerebral edema on CT was nonspecific and the absence of a demonstrable infarct on MRI limited etiological certainty.
Short in-hospital follow-up and subsequent loss to follow-up of the second patient precluded assessment of long-term neurological outcomes, functional recovery, and radiological evolution.

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Implication

Discordance between deficits and imaging in young stroke warrants integrated multimodal evaluation; leaves open optimal diagnostic strategies.

Abstract

Young-onset stroke can show discordance between clinical findings and imaging. A 25-year-old man presented with right hemiplegia and expressive aphasia (NIHSS 13). CT showed a hyperdense left middle cerebral artery sign and cerebral edema; MRI confirmed an early subacute left frontotemporal and corona radiata infarction. Initial cardiac evaluation identified no embolic source; the stroke was classified as cryptogenic with a suspected embolic mechanism. At discharge on day 7, the NIHSS score was 12 and right lower-limb strength was MRC grade 2/5. A previously healthy 21-year-old woman presented with left hemiparesis (NIHSS 3). CT showed diffuse sulcal effacement suggestive of mild cerebral edema, but MRI showed no acute infarction or focal structural lesion, and vascular imaging was unremarkable. Ischemic stroke remained clinically suspected without MRI confirmation. She was discharged on day 4 with persistent left-sided deficits. These cases highlight the need to integrate clinical assessment, multimodal imaging, and etiological evaluation.

Discussion

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Cite This Study

Kristijanto et al. (2026) conducted a case report in Young-onset acute ischemic stroke with clinicoradiological discordance (n=2). Multimodal neuroimaging and secondary stroke prevention (acetylsalicylic acid and atorvastatin) was evaluated on Clinical neurological status (NIHSS score and MRC muscle strength) and neuroimaging findings at discharge. Young-onset stroke showed clinicoradiological discordance in two cases: a 25-year-old with MRI-confirmed infarction (NIHSS 13 to 12) and a 21-year-old with DWI-negative deficits (NIHSS 3).

synapsesocial.com/papers/6af0dba03c845ca7837cedd8 https://doi.org/10.37897/rjn.2026.3.16

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Young-onset stroke with clinicoradiological discordance: a report of two cases

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Young-onset stroke with clinicoradiological discordance: a report of two cases

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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